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Contributors
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Ghizlane Aarab, DDS, PhD Department of Orofacial Pain and Dysfunction,
Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and
Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
Mohamed Abdelwahab, MD, PhD Sleep Surgery Division, Department of
Otolaryngology Head and Neck Surgery, Medical University of South Carolina,
Charleston, SC, USA
RakhaAbdelwahab, MD, PhD Department of Otolaryngology, Head and Neck
Surgery, School of Medicine, Mansoura University, Mansoura, Egypt
Vikas Agrawal, MD, MBBS, MS, DORL, FCPS Speciality ENT Hospital,
Mumbai, Maharashtra, India
Muhammad Firas Alhammad, MBBCH Department of Anaesthesia, ICU and
Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
Marco Barbieri, MD ENT Dept. IRCCS Ospedale Policlinico San Martino,
Genoa, Italy
Department of Surgical Sciences and Integrated Diagnostics (DISC), University of
Genoa, Genoa, Italy
Robson Capasso, MD, FAASM Division of Sleep Surgery, Department of
Otolaryngology-Head & Neck Surgery, Stanford University Medical Center,
Stanford, CA, USA
A.SimonCarney, BSc, MB ChB, FRCS, FRACS, DM College of Medicine and
Public Health, Flinders University, Adelaide, Australia
Adelaide Institute for Sleep Health, Flinders University, Adelaide, Australia
Joana Vaz de Castro, MD, Phd ISAMB, Medicine of University of Lisbon,
Lisbon, Portugal
Centro de Electroencefalograa e Neurosiologia Clínica (CENC), Lisbon, Portugal
Comprehensive Health Research Centre - CHRC, Lisbon, Portugal
PeterG.Catcheside, PhD, BSc(Hons), CRFS College of Medicine and Public
Health, Flinders University, Adelaide, Australia
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Contributors
Adelaide Institute for Sleep Health, Flinders University, Adelaide, Australia
PeterA.Cistulli, MD, PhD, MBA, FRACP Centre for Sleep Health and Research,
Royal North Shore Hospital, Sydney, NSW, Australia
Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
AbdulrahmanDardeer, FCAI, MCAI, ABHS-AIC Department of Anaesthesia,
ICU and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
MatejDelakorda, MD, PhD General Hospital Celje, Celje, Slovenia
DannyJ.Eckert, PhD College of Medicine and Public Health, Flinders University,
Adelaide, Australia
Adelaide Institute for Sleep Health, Flinders University, Adelaide, Australia
MarcoFragale, MD Department of Medical and Surgical Sciences and Advanced
Technologies “GF Ingrassia”, ENT Section, University of Catania, Catania, Italy
Michael Friedman, MD, FACS Division of Sleep Surgery, Department of
Otolaryngology-Head and Neck Surgery, Rush University Medical Center,
Chicago, IL, USA
Department of Otolaryngology, Advanced Center for Specialty Care, Advocate
Illinois Masonic Medical Center, Chicago, IL, USA
Clemens Heiser, MD, PhD, MHBA Department of Otorhinolaryngology, Head
and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich,
Munich, Germany
Translational Neurosciences, University of Antwerp, Antwerp, Belgium
SimonD.Herkenrath, MD Department of Pneumology at the Protestant Hospital
Bergisch Gladbach, Solingen, Germany
AntoniusA.J.Hilgevoord, MD, PhD Department of Clinical Neurophysiology,
OLVG, Amsterdam, The Netherlands
Jean-PierreT.F. Ho, MD, DDS Department of Oral and Maxillofacial Surgery,
Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA),
University of Amsterdam, Amsterdam, The Netherlands
Department of Oral and Maxillofacial Surgery, Northwest Clinics, Alkmaar, The
Netherlands
ZhengfeiHuang, DMD, MSc Department of Clinical Neurophysiology, OLVG,
Amsterdam, The Netherlands
Stacey L. Ishman, MD, MPH Division of Pediatric Otolaryngology-Head and
Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
SrinivasKishore, MD, MBBS, MS AIG Hospitals, Hyderabad, Telangana, India
Contributors
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Bhik T. Kotecha, MBBCh, MPhil, FRCS, DLO Nufeld Health Brentwood,
Essex, UK
VijayaKrishnan, MD, MBBS, DNB, DLO, MNAMS Department of Snoring &
Sleep Disorders, Madras ENT Research Foundation, Chennai, Tamil Nadu, India
Jande Lange, MD, DDS, PhD Department of Oral and Maxillofacial Surgery,
Amsterdam UMC and Academic Centre for Dentistry Amsterdam (ACTA),
University of Amsterdam, Amsterdam, The Netherlands
Mickey Leentjens, MD Department of Otorhinolaryngology, OLVG, Location
West, Amsterdam, The Netherlands
FedericoLeone, MD Unit of Otorhinolaryngology– Head and Neck Surgery–
Snoring and OSA Research Centre, Humanitas San Pio X, Milan, Italy
Hsin-ChingLin, MD, FACS Department of Otolaryngology, Kaohsiung Chang
Gung Memorial Hospital, Kaohsiung, Taiwan
Sleep Center, Robotic Surgery Center, Center for Quality Management, Kaohsiung
Chang Gung Memorial Hospital, Kaohsiung, Taiwan
College of Medicine, Chang Gung University, Taoyuan and Kaohsiung, Taiwan
Department of Business Management and Institute of Biomedical Science, Institute
of Healthcare Management, National Sun Yat-sen University, Kaohsiung, Taiwan
RussellChung-WeiLin, MD Department of Otolaryngology, Kaohsiung Chang
Gung Memorial Hospital, Kaohsiung, Taiwan
Marina Carrasco-Llatas, MD, PhD, AP Department of Otorhinolaringology,
Hospital Universitario Dr. Peset, Valencia, Spain
Department of Otorhinolaryngology, IMED Hospital, Valencia, Spain
Frank Lobbezoo, DDS, PhD Department of Orofacial Pain and Dysfunction,
Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and
Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
BlazMaver, MD General Hospital Celje, Celje, Slovenia
DavideMocellin, MD IRCCS Ospedale Policlinico San Martino, Genoa, Italy
ENT Dept., Ospedale S.Paolo, Savona, Italy
FilippoMontevecchi, MD Forlì Private Hospitals, Forlì, Italy
CarlosO’ConnorReina, MD, PhD Head of Otorhinolaryngology Department in
Hospital Quironsalud, Marbella, Spain
Eli Van de Perck, MD, PhD Department of Otolaryngology– Head and Neck
Surgery, Antwerp University Hospital, Edegem, Belgium
Christel A. L.de Raaff, MD, PhD Department of Albert Schweitzer Hospital,
Dordrecht, The Netherlands
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Contributors
Winfried J. Randerath, MD, FCCP, FATS, FAASM Internal Medicine,
Cardiology and Sleep Medicine, Bethanien Hospitzal, Clinic of Pneumology and
Allergology, Center for Sleep Medicine and Respiratory Care, Institute of
Pneumology at the University of Cologne, Solingen, Germany
Internal Medicine, Pneumology, Allergology, Sleep Medicine, Palliative Medicine,
Bethanien Hospital Clinic of Pneumology and Allergology, Center for Sleep
Medicine and Respiratory Care, Institute of Pneumology at the University of
Cologne, Valencia, Spain
MadelineJ.L.Ravesloot, MD, PhD, MSc Department of Otorhinolaryngology,
OLVG, location West, Amsterdam, The Netherlands
Fabrizio Salamanca, MD Unit of Otorhinolaryngology – Head and Neck
Surgery– Snoring and OSA Research Centre, Humanitas San Pio X, Milan, Italy
Department of Biomedical Sciences, Humanitas University, Milan, Italy
NabilA. Shallik, MD, MSc Department of Anaesthesia, ICU and Perioperative
Medicine, Hamad Medical Corporation, Doha, Qatar
Department of Clinical Anesthesiology, Weill Cornell Medical College in Qatar, Al
Rayyan, Qatar
Department of Clinical Anesthesiology, Qatar University, Doha, Qatar
Ashley L. Soaper, MD Division of Pediatric Otolaryngology-Head and Neck
Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
OlivierM.Vanderveken, MD, PhD Department of Otolaryngology—Head and
Neck Surgery, Antwerp University Hospital, Edegem, Belgium
Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
Johan Verbraecken, MD, PhD Department of Pulmonary Medicine and
Multidisciplinary Sleep Disorders Center, Antwerp University Hospital,
Edegem, Belgium
University of Antwerp, Antwerp, Belgium
ThomasVerse, MD, PhD Department for Otorhinolaryngology, Head and Neck
Surgery, Asklepios Klinikum Hamburg, Asklepios Campus, Hamburg, Germany
Claudio Vicini, MD Department of Otolaryngology and Head-Neck Surgery,
Morgagni-Pierantoni Hospital, Forlì, Italy
PattyE.Vonk, MD, PhD Department of Otorhinolaryngology, Academic Medical
Center Amsterdam, Amsterdam, The Netherlands
Nico de Vries, MD, PhD Jan Tooropstraat, Onze Lieve Vrouwe Gasthuis,
Amsterdam, The Netherlands
Cynthia S. Wang, MD Division of Pediatric Otolaryngology-Head and Neck
Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Contributors
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Markus Wirth, MD Department of Otolaryngology Head and Neck Surgery,
Technical University Munich, Munich, Germany
Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry
Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands
Department of Otorhinolaryngology–Head and Neck Surgery, OLVG, Amsterdam,
The Netherlands
Ning Zhou, MSc Department of Oral and Maxillofacial Surgery, Amsterdam
UMC and Academic Centre for Dentistry Amsterdam (ACTA), University of
Amsterdam, Amsterdam, The Netherlands
Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry
Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands
List of Videos
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Video 6.1 The effect of oral positioning on upper airway
Video 8.1 Complete anteroposterior obstruction caused by oppy epiglottis and
the effect of jaw thrust
Video 8.2 Complete anteroposterior obstruction caused by oppy epiglottis and
the effect of lateral head rotation
Video 8.3 Complete anteroposterior epiglottic collapse, secondary to a collapse
of the tongue base
Video 8.4 Complete lateral epiglottic collapse and the effect of jaw thrust
Video 11.1 (a, b) Congenital laryngomalacia on direct laryngoscopy. (c) Congenital
laryngomalacia immediately after supraglottoplasty
Video 11.2 Sleep-state laryngomalacia during a drug-induced sleep endoscopy
Video 15.1 DISE-CPAP performed to evaluate the best mask to be attached to CPAP
Video 15.2 DISE-CPAP titration with different pressures and jaw thrust maneuvers
Video 16.1 An example of conventional orofacial myofunctional speech ther-
apy for SDB
Video 16.2 Telemedicine orofacial myofunctional speech therapy based on sen-
sory motor rehabilitation
Video 16.3 An example of one of the exercises that the patient performs using the
Airway Gym app
Video 16.4 Pediatric orofacial myofunctional disorder
Video 16.5 Floppy epiglottis with anteroposterior collapse before and after 90 ses-
sions of orofacial myofunctional therapy (OMT)
Video 16.6 DISE video showing the epiglottis with lateral collapse before and after
orofacial myofunctional therapy (OMT)
Video 19.1 DISE demonstrating epiglottic trap door phenomenon
Video 19.2 TORS epiglottic resection with thulium laser
Video 20.1 Epiglottis Stiffening Operation (ESO) working area
Video 21.1 Epiglottic vallecula during performing the glossoepiglottopexy (GEP)
Video 21.2 Microlaryngoscopic view of the epiglottis at the end of the glossoepi-
glottopexy procedure (GEP)
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List of Videos
Video 22.1 (a) Passive contractions of the geniohyoid muscle (GH) and hyoid bone
during stimulation of the hypoglossal nerve visualized with an ultra-
sound. (b) Active contractions of the geniohyoid muscle (GH) and
hyoid bone during stimulation of the hypoglossal nerve visualized with
an ultrasound
Video 22.2 (a) Floppy epiglottis during drug-induced sleep endoscopy (DISE). (b)
The oppy epiglottis during drug-induced sleep endoscopy (DISE) is
solved by upper airway stimulation
Video 24.1 TORS tongue base reduction and supraglottoplasty
Video 25.1 Surgical technique of maxillomandibular advancement
Video 27.1 The effect of hypoglossal nerve stimulation on velum, lateral pharyn-
geal wall, tongue base, and epiglottis
Part I
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Introduction to OSA
OSA Epidemiology
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Hsin-ChingLin, RussellChung-WeiLin,
andMichaelFriedman
1.1 Introduction
Obstructive sleep apnea (OSA) is characterized by repetitive obstruction(s) of the
upper airway and arousal. OSA often results in episodic hypoxemia and abnormal
activation of the nocturnal sympathetic nervous system during sleep. Untreated
OSA is strongly associated with poor quality of life in nighttime and daytime as
well as an increase in cardio- and cerebro-vascular disorders [1–3].
The nighttime symptoms of OSA, such as habitual snoring, witnessed sleep
apneas, choking/gasping, restless sleep, frequent arousals, bruxism, night sweats,
gastroesophageal reux, and frequent nocturia, are commonly reported by the
1
H.-C. Lin (*)
Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital,
Kaohsiung, Taiwan
Sleep Center, Robotic Surgery Center, Center for Quality Management, Kaohsiung Chang
Gung Memorial Hospital, Kaohsiung, Taiwan
College of Medicine, Chang Gung University, Taoyuan and Kaohsiung, Taiwan
Department of Business Management and Institute of Biomedical Science, Institute of
Healthcare Management, National Sun Yat-sen University, Kaohsiung, Taiwan
e-mail: hclin@adm.cgmh.org.tw
R. C.-W. Lin
Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital,
Kaohsiung, Taiwan
M. Friedman
Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery,
Rush University Medical Center, Chicago, IL, USA
Department of Otolaryngology, Advanced Center for Specialty Care, Advocate Illinois
Masonic Medical Center, Chicago, IL, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
M. Delakorda, N. de Vries (eds.), The Role of Epiglottis in Obstructive Sleep
Apnea, https://doi.org/10.1007/978-3-031-34992-8_1
3
4
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H.-C. Lin et al.
patients and their bed-partners when they visit the sleep-related clinic. The daytime
symptoms of OSA, which may not be recognized by the patients themselves as
OSA-induced problems, include excessive daytime sleepiness (EDS)/hypersomnolence, morning headache, neurocognitive impairment, vigilance, motor coordination, mood and personality changes, depression, anxiety, irritability, sexual
dysfunction, and so on.
Common risk factors for OSA include obesity (the most important risk factor),
upper airway abnormalities, male gender, menopause, and age [4, 5]. Numerous
characteristic ndings of physical signs from the nasal cavity, pharyngeal space, and
craniofacial structure could be signicantly associated with upper airway obstruction in suspected OSA patients. Some of them require complex measurements with
exible beroptic observations or radiographs, whereas other measures will change
in response to maneuvers, such as using a exible nasopharyngoscopy with the
Müller maneuver. These signs of OSA are obesity, increased neck circumference,
retrognathia (a.k.a. mandibular retroposition), nasal valves narrowing, deviation of
the septum, turbinate hypertrophy, adenoid hypertrophy, short lingual frenulum,
macroglossia (often associated with lateral lingual scalloping by adjacent teeth),
tonsil hypertrophy, redundant peripharyngeal tissue and soft palate, high arched palate, elongated uvula, higher Friedman tongue position (intraoral tongue position
relative to the palatal degree of exposure) [6], prominent lateral pharyngeal walls,
oppy epiglottis, etc..
Although the understanding of OSA’s entirety and its impact on healthcare still
continues to evolve and remain challenging, it is clear that OSA is an important
cause of morbidity and mortality. Intermittent hypoxemia (IH) of OSA is now being
recognized as a potentially major factor contributing to the pathogenesis of OSArelated comorbidities [7]. IH can promote oxidative stress by increased production
of reactive oxygen species and angiogenesis, increased sympathetic activation with
blood pressure elevation, and systemic and vascular inammation with endothelial
dysfunction. Data from observational studies in large population groups support the
role of hypoxia in the pathogenesis of OSA comorbidity as well.
OSA is well recognized as an independent risk factor for cardiometabolic comorbidities, such as hypertension, coronary heart disease, arrhythmia, stroke, and metabolic disorders (e.g., diabetes and dyslipidemia). Traditionally, patients suffering
from more severe OSA, longer time of sleep apneas/hypopneas, frequent nocturnal
hypoxemia, and worse sleep quality are more likely to develop cardiometabolic
comorbidities and neurocognitive decline [8]. The neurobehavioural morbidities of
daytime sleepiness and impaired cognitive function may contribute to motor vehicle
and job-related accidents [9, 10].
In addition, OSA signicantly increases the risk of stroke or death from any
cause; in an observational cohort study with 1022 community-based patients, moderate to severe sleep apnea is independently associated with a signicantly increased
risk of all-cause mortality [11].
OSA patients also commonly contend with comorbid psychiatric conditions,
including depression, insomnia, and anxiety. The most common mood disorder
associated with OSA is depression. Comprehensive reviews report increased rates
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